STEPHANIE BLOUNT had been thrown out of one care home for being too aggressive toward fellow residents, records show. But when Blount arrived at CC’s Adult Residential Care Home No. 3 in Concord, she was lethargic to the point that she was unable to
feed herself and was sleeping for much of the day, the home’s care notes show.

She died on April 6, 2001,
just three days after her 20th
birthday and less than three
weeks after she came to live at
the home, licensing records
show.

Blount is one of 15 people
who died in East Bay care
homes for the developmentally
disabled, whose deaths are
chronicled in licensing records,
police and coroner’s reports
and other records dating back
to 1999. Two others died in San
Mateo County care homes.

Records provided by the regional center, which only date
back to 2002, show more
deaths than do licensing reports. But they don’t say where
those people lived or how they
died, so it is unclear how many
died in care homes or why they
died.

Blount’s death offers a
window on the limitations of the
care system set up to manage
developmentally disabled peoples’ lives.

The homes are not meant to
be medical facilities. But they
house people whose disabilities
make them more medically
fragile than the average person,
says Dr. Matt Holder, executive
director for the American
Academy of Developmental
Medicine and Dentistry, which
is based in New Jersey.

Caregivers who work in the
homes are required to take 70
hours of basic, on-the-job
training. But Holder, who reviewed information on the
deaths at the newspaper’s request, believes they should get
more.

“In at least 10 cases, had the
staff had a higher level of medical training, these deaths (or
the preceding situations that led
to these deaths) may have been
avoided,” Holder says in an email to this newspaper following his review of the records.

Records for each case ranged
from a handful of licensing documents to more detailed accounts with coroner’s reports
and some medical information.
Detailed medical information
was not available for most of
the cases.

Life-saving training?

In some of the cases, staff
did not appear to have the
training or ability to resuscitate
the clients. In others, he says,
better training of doctors might
have prevented their deaths.

But community care providers say it’s tough to find psychiatrists, primary care
physicians or other medical
professionals who will see their
clients at all, let alone doctors
who specialize in their charges’
care because of the low rates
Medi-Cal pays and because
their clients are often difficult to
work with.

“We have to sometimes resort to emergency rooms,” says
Wardell Jackson, president of
the Association of California
Care Operators and a care
home operator.

Some of the deaths were
likely unavoidable, Holder says.
And it’s hard to say for sure
who, if anyone, may have been
at fault for the deaths.

State licensing officials say
they investigate “suspicious”
deaths — those which don’t appear to be the result of natural
causes. Regional Center of the
East Bay officials say they review every death, though they
don’t do further investigation
once they determine a death is
natural. And they don’t have the
authority to discipline doctors
or other medical providers who
may be responsible for their clients’ deaths.

Coroners don’t do autopsies
on everyone who comes into their morgue, says Sgt. Daryl
England, a former Contra Costa
County coroner. People with developmental disabilities could
die of a number of natural
causes.

“It’s tragic. But it’s not important which natural cause
killed them,” he says, discussing one case his office handled.

Based on an external exam, a
Contra Costa County pathologist originally determined
Blount died of natural causes
from a seizure disorder due to
her cerebral palsy. But the Regional Center of the East Bay
pushed for an autopsy.

The autopsy results showed
Blount, who was also mentally
retarded, autistic and schizophrenic, died of multisystem
organ failure. She had a staph
infection and pneumonia, the
coroner’s report shows.

The home’s staff was unable
to get an appointment to refill
Blount’s medications until
nearly a week after they ran out,
licensing records show. Blount
was on several different medications including an antidepressant and antiseizure
medication.

CC’s co-owner Cecilia
Hawkins says Blount came to
her as an emergency placement
from Contra Costa Regional
Medical Center, where she had
been placed from her previous
care home on a psychiatric
hold.

She went to Blount’s former
home to pick up her personal
things and her paperwork but
could not remember what paperwork she got. She declined
to comment further.

A doctor asked by licensing
investigators to review Blount’s
case — who noted that she had
“decompensated” in her earlier
care home in the months before
she was sent to the hospital,
banging her head and making
jerky movements throughout an
earlier exam — say the lack of
medications likely didn’t contribute to her death but that she
probably should have been in a
facility offering more skilled
care.

One expert says it’s hard to
know what effects a given combination of drugs could have on
someone because often, it’s just
not well-known. Information on
drug interactions is often more
theory than actual knowledge,
says Michael Negrete, a pharmacist and vice president of
clinical programs for the California Pharmacists Association.
And people’s bodies can react
differently to the same drug, he
says.

“If you’re on more than four
or five medications, you need to
have somebody do a medical
check of all these things,” Negrete says, adding that a pharmacist would be the best
person to review medications
with.

California’s nursing homes
and other long-term care facilities must have a pharmacist do
monthly medication reviews of
their patients, he says.

Troubles from the start?

The four-bed home, which
had only been open for a few
months when Blount died, had
some troubles from the start.
The licensing worker who reviewed Hawkins and co-owner
Conchita Gozun’s application to
open the home noted that the
pair needed to keep up with
changes in regulations.

(Hawkins owned two other
care homes and Gozun worked
as an administrator in one of
Hawkins’ other homes.)

A licensing worker who
made a pre-licensing visit to the
home noted seven deficiencies,
most of them in the home’s
physical plant.

In Blount’s case, licensing
cited the home for taking her in
because couldn’t walk, a violation of the home’s fire clearance; failing to plan for her
needs; failing to refill her medications; and failing to record
her medication information on
a medication log as required.

The agency put the home
and another owned by Hawkins
on a compliance plan requiring
them to meet their legal obligations and to other conditions,
including medication training
for the homes’ owners and staff.
Licensing would monitor the home more closely for 12
months and could move to
close the home if it did not
comply with the plan.

But the home was cited for
several more deficiencies in two
visits during that year, including some which had been
identified as problems during the investigation into Blount’s
death. The home was cited for
three repeat deficiencies during
that time.

Still, the home remained
open.

Blount, who had been a ward
of the state since 1984, received
a county burial.

Not only was racial animus a likely factor when Charter Communications repeatedly rejected negotiations with Entertainment Studios, the TV programmer, but Charter's attempt to shield itself from allegations of bias using the First Amendment is also without merit, according to the U.S. Court of Appeals for the Ninth Circuit.